1. business and industrial

Owner Operator Application
Any Individual wishing to conduct business with Express Courier as an Owner Operator must meet DOT standards.
Information solicited will be used to determine eligibility and will not be used for any purposes prohibited by law.
SSN:
Name:
Birth Date:
First
Middle
Last
Address:
Home Phone:
City
Fax:
Zip
State
Zip
Email:
Previous Address:
City
How long at this address:
State
Do you have computer access at home? Yes  No 
Do you have the legal right to work in the United States? Yes 
No 
Have you ever had an agreement with Express Courier as an Owner Operator? Yes  No 
If yes, indicate dates:
Have you ever been an Employee of Express Courier? Yes 
If yes, indicate dates:
No 
Company Location:
Position:
_
Reason for leaving:
Are you now under contract of Employment? Yes  No 
How long since termination of your last Owner-Operator agreement or last employment?
How did you hear about this opportunity?
Date you can start:
Type of Vehicle:
In the past 3 years, have you ever knowingly used any narcotics, amphetamines, or barbiturates, other than those prescribed by a
physician? If yes, explain:
*Have you ever been convicted of a criminal offense including either a felony or misdemeanor charge? Yes  No 
If Yes, please provide the following information for each charge:
Charge:
City:
County:
State:
Date of Arrest:
Date of Final Disposition:
Charge:
City:
Date of Arrest:
Court where case was handled:
County:
State:
Court where case was handled:
Date of Final Disposition:
Page 1 of 43
*Are you currently charged with committing a criminal offense including either a felony or misdemeanor charges? Yes 
No 
Charge: ___________________________________________________ County: __________________________________________
City: _____________________________ State: ______________ Court where case was handled: ___________________________
Date of Arrest: _______________________________ Date of Final Disposition: ________________________________
Describe the Final Disposition: ___________________________________________________________________________________
Owner Operator contracts require flexibility in scheduling. Please list the days and hours, you are generally
available for service:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
From:
_____________ _____________ _____________ _____________ _____________ _____________ _____________
To:
_____________ _____________ _____________ _____________ _____________ _____________ _____________
Accident Record For the Past 3 Years or More
Date of Accident: ___________________________ Nature of Accident: ________________________________________________
Number of Fatalities: ________________________ Number of Injuries: ________________________________________________
Date of Accident: ___________________________ Nature of Accident: ________________________________________________
Number of Fatalities: ________________________ Number of Injuries: ________________________________________________
Date of Accident: ___________________________ Nature of Accident: ________________________________________________
Number of Fatalities: ________________________ Number of Injuries: ________________________________________________
Traffic Convictions and Forfeitures for the past 3 years (Other than parking violations)
Date of Violation: __________________________ Location: ___________________________ Charge: _______________________
Penalty: ___________________________________________________________________________________________________
Date of Violation: __________________________ Location: ___________________________ Charge: ______________________
Penalty: ___________________________________________________________________________________________________
Date of Violation: __________________________ Location: ___________________________ Charge: _______________________
Penalty: ___________________________________________________________________________________________________
Education:
Grade School: 8
High
High School: 0
College: 0
Name of last school attended: ____________________________________________ City/State: _____________________________
Experience and Qualifications
Driver License Number: ______________________________________ State of Issue: _______________________________
Type: ______________ Expiration Date: ___________________ Name as it appears on License: ___________________________
Driver License Number: ______________________________________ State of Issue: _______________________________
Type: ______________ Expiration Date: ___________________ Name as it appears on License: ___________________________
Driver License Number: ______________________________________ State of Issue: _______________________________
Type: ______________ Expiration Date: ___________________ Name as it appears on License: ___________________________
1.) Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes 
2.) Has any license, permit or privilege ever been suspended or revoked? Yes 
No

No 
If you answered yes to either 1 or 2, please explain:
____________________________________________________________________________________________________________________
Page 2 of 43
List special courses or training that will help you as a driver:
Which Safe Driving awards do you hold and from whom?
Previous Employment or Owner Operator History
All Owner-Operator applicants to drive commercial motor vehicles weighing at least 10,000 lbs must provide the following
information on all previous employers or entities with which the applicant contracted during the past 3 years. Applicants to
drive commercial motor vehicle with a gross combination weight rating 26,001 lbs or more shall also provide an additional 7
years information on those previous employers or entities for whom the applicant operated such vehicle.
Entity Name:
Address:
Phone Number:
Contact Person:
City
State
Salary/Wage:
Zip
Position:
Reason for leaving:
Contract/Employment Start Date:
Contract/Employment Termination Date:
Entity Name:
Address:
Phone Number:
Contact Person:
City
State
Salary/Wage:
Zip
Position:
Reason for leaving:
Contract/Employment Start Date:
Contract/Employment Termination Date:
Entity Name:
Address:
Phone Number:
Contact Person:
City
Salary/Wage:
State
Zip
Position:
Reason for leaving:
Contract/Employment Start Date:
Contract/Employment Termination Date:
Page 3 of 43
To Be Read and Signed by Applicant
By affixing my signature below, I understand and agree that as part of the procedure for processing this application, the
Company may investigate all facts and statements presented here. This inquiry may include information as to my character,
general reputation, and prior work habits, whichever may be applicable. My signature below releases from liability all
persons and/or organizations supplying or collecting such information. I hereby authorize a representative of the
Company to inquire as to my record with any and all of my former employers or companies I have previously contracted
with. I further understand and agree that any false statements or answers made by me on this application or supplement
thereto, will be grounds for the company to dissolve any agreements. I understand and agree that my contract and
compensation can be dissolved, with or without cause, and with or without notice, at any time, at my option or the option of
the Company, and that no manager or supervisor other than the President of the Company or his duly authorized
representative has any authority to enter into any other agreement for any specified period of time, or to make any
agreement contrary to the foregoing.
Date
Owner-Operator’s Signature
NOTICE
In compliance with the Department of Transportation, and before entering into an agreement with Express Courier,
you may be required to have physical examination by a licensed physician. The cost of the physical is solely the
responsibility of the Owner- Operator.
Included in the examination is a hearing test, vision test, a comprehensive medical and occupational history
questionnaire, vital signs, height, weight, a general physical examination and a urine drug screen. Additionally,
if you are offered a run or route, which requires the ability to lift, you may be administered relevant tests.
Results of the physical will be submitted under confidential cover to a Company representative. Where test results
indicate the presence of illicit drugs and/or undeclared pharmaceutical and/or alcoholic substances, or other
conditions, which the Department of Transportation has deemed to be unacceptable, the offer of a contract must be
rescinded without penalty to the Company.
By affixing your signature below, you can certify that you have been advised, via this notice, of the test which may be
conducted and that you voluntarily agree to submit to such testing, if required, following an offer of a contract.
Furthermore, you will authorize release of the test results to the responsible agent of our Company, and
acknowledge that you understand and agree to all conditions state above.
Date
Owner-Operator’s Signature
Page 4 of 43
Owner-Operator Qualifications
Prior to orientation acceptance, all new Owner Operator applicants must provide a current Motor Vehicle Report
from the state in which the applicant’s driver’s license was issued. In addition, Motor Vehicle Reports will be
checked annually on all Owner Operators under contract.
Any applicant or driver whose record has any of the following characteristics in the last 5 years does not meet
the requirements and will be declined or their contract will be terminated.
















Driving under the influence
Driving while impaired
Driving while in possession of alcohol or drugs
Driving with a suspended or revoked license
Vehicular manslaughter
Vehicular homicide
Vehicular assault
A felony in which a vehicle is used
Reckless driving
Hit and run
Eluding a police officer
Refusal to submit to a blood, urine, or breathalyzer test
Speeding exceeding 100 mph (or speeding in excess of 25 mph over the limit)
Speed contest / drag racing
More than two at-fault accidents, or four moving violations
Other violations and accidents on MVR will be reviewed by Express compliance for acceptability
I have read and understand the above OO Qualifications requirements.
Owner Operator’s Signature:
Date:
Page 5 of 43
Branch: Branch
Operator # ___
___________
___________
___
Owner O
_
____ _______
____________
___________
___________
________ ___
___________
___________
___________
Name: __
Firrst
Mid
ddle
Last
____________
_ _________
____________
___________
______ ____
____________
____________
___
____ ______
Address:: __________
City
State
Zip
Number: _____
___________
______ Startt Date: _____
___________
_____
Phone N
___________
License Numb
ber: _______
___________
____________
____ State: _
________ Exxpiration Date
e: _________
____
Driver’s L
____________
___________
__ Birth Date
e: _________
___________
___________
SSN: __
Vehicle Information
n
___________
________ Ve
ehicle Model: ___________
_
___________
___________
Make: ______
_______ Yea
ar: _________
____
Vehicle M
____________
____________
____ Color: _
___________
___________
___________
___________
___
VIN: ____
____________
_ State: ____
___________
_______ Exp
___________
____________
Tag: _______
piration Date: ___________
____
License T
Insurance Informattion
___________
___________
____________
___________
____________
___________
___________
e Carrier: ____
bile Insurance
Automob
____
___________
______ ____
____________
____________
____________
_ _________
____________
____ ______
___
Address:: __________
City
State
Zip
_____ Policy
_____
___________
Number: _____
___________
y Number: ___
___________
____________
____________
Phone N
__________ Expiration Da
___________
___
ate: ________
___________
___________
Effective Date: ______
___________
___________
Name: ______
___________
________
____________
__ Phone Num
mber: ______
___________
Agent’s N
___________
___________
Address: ____
____________
___________
____________
___________
___________
___________
Agent’s A
____
____________
____________
Amount: ____
____________
___________
_________ Property
P
Dam
mage Amount:: __________
____
Liability A
ST BE FAXED
S FORM MUS
UIRED: THIS
EHICLE
LICENSE, VE
D TO CORPO
ORATE WITH A COPY OF
F DRIVER’S L
****REQU
F INSURANC
RATION, AND PROOF OF
BER,
CE INCLUDIN
NG INSURAN
NCE COMPAN
NY NAME, POLICY NUMB
REGISTR
VE
A
TION DATE, LIABILITY AMOUNTS,
ED.
EHICLE(S) COVERED,
C
A
AND NAME(S)) OF INSURE
EXPIRAT
Page 6 of 43
PE
ERSONAL
L DATA R
RECORD
Branch
BRANCH
H __________
_______
R # _________
________
OWNER OPERATOR
CONTRAC
CTOR INFOR
RMATION
NAM
ME
ADDR
RESS
CIT
TY
STATE
S
ZIP
TELEPH
HONE
CEL
LL
PHO
ONE
EMA
AIL
ADDR
RESS
EMERGENCY
Y CONTACT INFORMATIO
ON
NAM
ME
ADDR
RESS
CIT
TY
STATE
ZIIP
TELEP
PHONE
CELL P
PHONE
DATE
NOTES
1.______
__________
_________
____________
____________
___________
___________
____________
____________
___________
____
2.______
__________
_________
____________
____________
___________
___________
____________
____________
___________
____
3.______
__________
_________
____________
____________
___________
___________
____________
____________
___________
____
4.______
__________
_________
____________
____________
___________
___________
____________
____________
___________
____
Page 7 of 43
NOTICE – BACKGROUND INVESTIGATION AUTHORIZATION
In connection with your application and/or employment with (_______________________________) (Employer) this notice is
provided to inform you that a “consumer report” and/or “investigative consumer report”, as defined by the Fair Credit Reporting Act,
may be obtained from a consumer reporting agency for employment purposes. These types of reports may include information as to
your character, general reputation, personal characteristics and mode of living, whichever are applicable. The report may also contain
information about you relating to criminal history, credit history, driving and/or motor vehicle records, social security verification,
verification of your education or employment history or other background checks. They may involve interviews with sources such as
your neighbors, friends or associates. Reports may be obtained any time after receipt of this authorization and if hired, throughout the
course of your employment, as permitted by law. You have the right, upon written request made within a reasonable amount time
after the receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report to Confirm Choice,
4205 Hillsboro Pike, Suite 200, Nashville, TN 37215, toll free number 1-888-925-0114. For information about Confirm Choice’s
privacy practices, see www.confirmchoice.com. The scope of this notice and authorization is not limited to the present and, if hired,
will continue and allow Employer to conduct future screenings for retention, promotion or reassignment, unless revoked by you in
writing. Employer also reserves the right to share such reports with a third-party for whom you will be placed to work as a
representative of Employer, if applicable.
Acknowledgement and Authorization
By signing below you acknowledge receipt of a copy of the A Summary of Your Rights under the Fair Reporting Act and certify that
you have read this notice and authorization as well as the summary.
You hereby authorize, without reservation, the obtaining of a “consumer report” and/or “investigative consumer report” at any time
after receipt of this authorization and during the course of your employment, to the extent permitted by law. You also confirm your
understanding and provide consent for this report to be shared with a third-party for whom you may be placed to work as a
representative of Employer, if applicable.
Minnesota & Oklahoma applicants or employees only: Under state law you have a right to receive a copy of your consumer report, free of charge, if one is
requested by Employer. By checking “yes”, a copy will be provided to you at the address you provide on this notice.
I would like to receive a copy of my consumer report: (___) Yes (___) No
New York applicants or employees only: Under state law you have the right to inspect and receive a copy of any investigative consumer report requested by
Employer by contacting Confirm Choice directly. You also acknowledge receipt of a copy of Article 23-A of the New York Correction Law by signing this notice.
Washington State applicants or employees only: Under state law you have a right to request a copy of the Washington Fair Credit Reporting Act’s disclosures to
consumers (RCW 19.182.070) by contacting Confirm Choice directly.
California, Maine applicants or employees only: Under state law you have a right to receive a copy of your investigative consumer report and/or consumer credit
report, free of charge, if one is requested by Employer. By checking “yes” a copy will be provided to you at the address you provide on this Notice.
I would like to receive a copy of my consumer report: (___) Yes (___) No
_____________________
Social Security Number*
Signature
Today’s Date
Print Full Name
__________________________________________________
Other names you have used
___________________________________________
Date of Birth*
Driver’s License Number & State Issued
Name as it appears on Driver’s License
Current Address
City
State
Zip
Previous Address 1: ___________________________________________________________________________________
Previous Address 2: ___________________________________________________________________________________
* This information will be used for employment-related background screening purposes only and no other purpose.
3/19/13
___________
__
________
Date
n: Express Co
ourier
Attention
are that consu
umer and mo
otor vehicle re
eports may be
I am awa
e obtained ass part of Exprress Courier IInternational’ss evaluation of
o my
Operator agreement execu
ution. The re ports
p
may be procured byy Express Cou
mpany
Owner-O
urier Internatiional or its in surance com
ntative(s), and
d may include
e personal in
nformation ob
d, an
represen
btained from sstate motor vvehicle deparrtments, my driving record
ment of my insurability for th
he insurance program,
p
or other
o
assessm
consum
mer reports.
ng this letter, I hereby provide my auth
horization for Express Cou
Be signin
urier Intl. or th
heir insurance
e company re
epresentative(s) to
s additional report
re
aluate
procure ssuch informattion and reports, as well as
about m
me from time--to-time as de
eemed approp
priate, to eva
ability or for other
o
permissiible purposes
s.
my insura
Sincerelyy,
___________
___________
________
________
Operator’s Sig
gnature
Owner-O
_____
____________
___________
__
Owne
er-Operator #
Branch ___________
___________
________
________
Branch
________ __
________
___________
___________
____________
____________
____________
_______ ___
____________
_________
Name ass it appears on
Drriver’s License
n Driver’s Lice
ense
e Number
Sttate Issuing Liicense
____________
________
___________
___________
_ __________
___ _______
___________
__________
Date of B
Birth
Gender
Social Se
ecurity Numb
ber
Page 9 of 43
COMPANY PROPERTY RECEIPT
Owner-Operator #
Name
Date_
My signature below acknowledges that I,
_, will be provided for my
use while serving as an Owner-Operator on behalf of Express Courier, Inc., or will lease from the company the
following items: (A) cooler, (B) vehicle sign, (C) pager, (D) communication device, (E) Spill Kit
The following items have been provided to me by Express Courier, Inc. and I understand I will be charged a
reasonable fee for their use. In the event that my contract is terminated for any reason, I will promptly return all items.
A)
COOLER
(1) Thermos Cooler - Replacement Cost $50.00
B)
TRUCK SIGNS
(2) Truck Signs. I understand it is ICC policy to display these signs while
performing delivery services for the company.
Replacement cost $10.00 each.
C)
PAGER
(1) Pager - Replacement Cost $100.00
D)
COMMUNICATION
DEVICE
(1) Phone – Replacement Cost $200.00
Phone No.
Serial No.
E)
Spill Kit
(1) AC Adapter Cost $43.25
(1) Belt Clip Cost $10.81
(1) $8.00
IT IS HEREBY UNDERSTOOD AND AGREED UPON THAT REIMBURSEMENT FOR LOST OR DAMAGED
ITEMS MAY BE DEDUCTED FROM MY FINAL COMMISSION CHECK AT THE COSTS DESIGNATED ABOVE.
SIGNATURE
SIGNATURE
(OWNER-OPERATOR)
(EXPRESS COURIER MANAGEMENT)
DATE
DATE
Page 10 of 43
Owner Operator Scanner Inventory Control Form
Location Name:
O/O Name:
Date:
O/O Number:
I,
, acknowledge receipt of the following said equipment and agree to
a deduction from my weekly settlement for the associated costs. I understand that I am solely responsible for the
equipment and will be held accountable should it be lost, stolen or broken beyond repair. Further, I understand
that should termination of contract occur, I will be expected to immediately return said equipment. If I neglect to
return the equipment, the amount necessary to replace the equipment will be due within ten (10) days of the
contract termination date. I hereby consent to Express Courier International, Inc. deducting from any
settlement commissions due me the value of any equipment I do not return, the cost of repair of the
damaged equipment, or the cost associated with the repair of any damaged equipment. If I do not
reimburse ECI in full for the said equipment, I understand that I will be responsible for any legal fees incurred by
ECI in an effort to seek reimbursement. If scanner is damaged due to abuse or negligence a $25 handling fee
will be deducted for shipping and handling.
Scanner Unit
Unit Number
SIM Number
Serial Number
Replacement Cost
$ 1,881.89
Stylus Cost
$
5.00
Holster Cost
$
32.50
Car Charger
$
74.00
Wall Charger
$
82.00
***Commissions are calculated on four-week average of scan deliveries***
OO Signature:
Date:
ECI Representative Signature:
Date:
Page 11 of 43
Dispatch Notification Form
Owner-Operator Number:
Owner-Operator Name:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Type of Vehicle:
What part of town do you sign on in?
Page 12 of 43
POLICY AND PROCEDURES
FOR OWNER-OPERATORS
The company has various types of runs or services, which may be offered to you on a regular basis. Our dispatchers
determine who is available to handle a given run based on the availability of owner-operators.
When a run is offered to you, you have the right under your contract with us to refuse the run. If you choose to do so, you
must notify dispatch immediately so that the run can be offered to another owner-operator.
The company does not set service hours for owner-operators. As a owner-operator, you have the flexibility of setting
your own service hours and are a master of your own time. At the same time, however, the Company knows when runs
are available and what our customer’ time requirements are. Therefore, to maximize your income and to assist in
facilitating run assignments, it is advisable that you work with dispatch to determine the hours you will be available for
service each day or each week. If you intend to take an extended period of non-service for any reason, it is requested
that you provide dispatch with a minimum of five (5) days notice of this activity so that we can make arrangements with
other owner-operators.
I have read, understand, and agree to comply with the above Policy and Procedures.
Owner-Operator’s Signature
Date
Page 13 of 43
Anti-Harassment Policy
Express Courier International, Inc. is committed to providing all owner-operators the opportunity to pursue excellence and
profitability in their professional driving careers. As a condition to a continual contractual relationship, Express Courier
International, Inc. expects owner-operators, doing business on behalf of ECI and their customers, to conduct
themselves in a professional manner at all times. This can only be achieved when there is a mutual respect for all
individuals with whom owner- operators may come into contact with daily. Express Courier International, Inc. has a zero
tolerance policy regarding any form of harassment. Comments, words, jokes, suggestive gestures or actions made to
any individual, or that may be overheard or seen by them based on an individual’s sex, race, ethnicity, age, religion,
veteran status or any other legally protected characteristic will not be tolerated. Any form of harassment (both overt
and subtle) is a form of misconduct that demeans another person and undermines the integrity of the business
relationship established between ECI and the owner-operators and customers. Thus, it is strictly prohibited. This policy is
applicable to all owner-operators at all times they are in performance of their duties on behalf of ECI.
I have read and understand the above Anti-Harassment Policy.
Owner-Operator’s Signature
Date
Page 14 of 43
CONFIDENTIALITY STATEMENT
CONFIDENTIALITY REQUIREMENTS - PROTECTING THE PRIVACY OF PATIENTS’ HEALTH INFORMATION
1. INFORMATION REQUIRED TO BE PROTECTED
The privacy of all medical records and other individually identifiable health information must be protected at all times.
Information relating to a patient’s health care history, diagnosis, treatment, or evaluation shall be considered
individually identifiable health
information. Confidentiality of their health information must be maintained at all times, and may only be disclosed
with the express written consent of the patient.
Non-individually identifiable health information (e.g. health information that cannot be linked to a specific patient) is not
included with in the definition of protected health information.
2. BOUNDARIES ON HEALTH INFORMATION USE AND RELEASE
An individual’s health information can be used for health purposes only.
a.
Protect individually identifiable health information. Express Courier shall not publish or otherwise
make generally available any information or data that identifies a patient for purposes other than treatment,
payment or other health care operations, without his or her express written consent. This does not restrict the
internal use of such information or data that is required in the Express Courier also maintains physical, electronic
and procedural safe guards to protect safeguards and expect to make ongoing improvements to maintain and
enhance our level of security for individually identifiable health information.
b.
Ensure that health information is not used for non-health purposes. Patient information can be
used or disclosed only for purposes of health care treatment, payment, and operations. Health information cannot
be used for purposes not related to health care without explicit authorization from the patient.
For example, Express Courier may not access the personal health information obtained by an Express Courier affiliate
for any purpose other than to perform the services for which we were engaged, unless Express Courier first obtains
the explicit authorization of the patient.
c.
Maintain health information in a manner to protect confidentiality.
All individually identifiable
health information shall be maintained by Express Courier in a confidential manner which prevents
unauthorized or inadvertent disclosure to third parties.
For example, Express Courier may share confidential information with a third party under contract or affiliated
with Express Courier for the same purpose of performing the services which we were engaged, providing that the
information shall remain confidential at all times and shall be shared with only those persons that have authority to
receive such information.
PENALTIES FOR MISUSE OF PERSONAL HEALTH INFORMATION
There are serious penalties for violation of the confidentiality of health information. Please be advised of the following:
State Penalties. Various state laws impose criminal and civil penalties on individuals who misuse or
disclose individually identifiable health information without explicit consent by the patient.
b.
Federal Penalties. HIPAA (Health Insurance Portability and Accountability Act) is a piece of federal
legislation that directly addresses the protection of confidential health information. This law is being phased in
over a two-year period. Once effective, HIPAA will provided civil money penalties up to $25,000 per person, per
year for violations of
patient confidentiality. HIPAA also provides for federal criminal penalties.
c.
Express Courier’s Penalties. Any owner-operator who violated the privacy and confidentiality of patient
health information, though disclosure or otherwise, may be subject to contract termination with Express Courier
International, Inc.
a.
I understand and agree that in the performance of my duties as an Owner-Operator of Express Courier International, Inc., I
must hold medical information in confidence. Further, I understand that intentional or involuntary violation of customer
confidentiality may result in punitive action including possible fine or imprisonment.
Owner-Operator’s Signature
Date
Page 15 of 43
ENVIRONMENTAL, HEALTH AND SAFETY
INFORMATION DRY ICE HANDLING
This information is being provided to make you aware of a potentially hazardous condition that exists when handling DRY
ICE, or SOLID CARBON DIOXIDE. Please ensure that all personnel who may come into contact with this substance read
this information sheet.
There are two hazards associated with handling dry ice: Carbon Dioxide intoxication and frozen
tissue.
CARBON DIOXIDE INTOXICATION
When concentrations of Carbon Dioxide in air reach approximately 10 times normal, the typical symptoms of Carbon
Dioxide intoxication include headaches, drowsiness, and perspiration.
Higher levels can add tremors, visual
disturbances, and finally unconsciousness. At much higher concentrations, Carbon Dioxide displaces the oxygen
percentage below the levels necessary to support life.
To minimize this hazard, ventilate indoor areas to avoid hazardous Carbon Dioxide concentrations. Carbon Dioxide is a
heave gas and will remain in low spots without assisted ventilation. Employees should avoid lowering their heads into dry
ice chests or in areas immediately adjacent to or in the proximity of materials packaged with dry ice. Carbon Dioxide will
displace the oxygen in these containers and you could pass out.
When transporting any amount of dry ice, be sure that the heating and air conditioner controls are set to the “Normal” or
“Vent” positions and roll down a window an inch or so. Avoid using the “Maximum” A/C setting, which will entrap the
Carbon Dioxide and elevate concentrations to dangerous levels.
FROZEN TISSUE
Direct contact of skin or eyes with dry ice causes the tissue to instantly freeze and be damaged. Damage to eyes
cannot be repaired.
Protective gloves (suitable for work with cryogens) and safety eyewear/face shields are
recommended when working with cold liquid, solid, or vapor. Be sure that you have some heave gloves in case you need
to handle the dry ice.
In the event of accidental contact, immediately report the incident to your driver supervisor.
To help ensure your safety, the following measures have been instituted:
Your work area where the dry ice is stored will be periodically monitored for levels of Carbon Dioxide. It must also be
monitored if the amount of dry ice stored is increased.
Your vehicle will be periodically monitored while you drive your route. If you are called upon to transport larger amounts of
dry ice than the routine amount, notify ECI so that your vehicle can be monitored.
Procedures for packaging Dry Ice for Air shipments
Under no circumstances are you to pack more then FOUR LBS of dry ice to ONE Styrofoam receptacle without written
permission by the air carrier.
Under no circumstances are you to pack more than ONE Styrofoam receptacle within one sealed box. Your dry ice
placards are to be placed on each end of the outside box with no more than 4lbs. written in the space provided.
I have read/reviewed the process for handling dry ice and have been given the opportunity to ask questions.
understand my responsibilities as an owner-operator when handling dry ice.
Owner-Operator’s Signature
I
Date
Page 16 of 43
OWNER-OPERATOR AGREEMENT
Express
Courier
International,
Inc.
(“CARRIER”),
an
authorized
motor
carrier,
and
(“OWNER-OPERATOR”), in consideration of the covenants and agreements contained herein and pursuant to the
federal leasing regulations under 49 C.F.R. Part 376, enter into this Owner Operator Agreement (“Agreement”) on
BBBBBBBBBBBBBBBBBBBBBBBBB
1.
PROVISION OF SERVICES AND EQUIPMENT. During the term of this Agreement, OWNER-OPERATOR shall
provide CARRIER transportation related services and the use of the equipment set forth below or in an appendix (the
“Equipment”). OWNER-OPERATOR represents and warrants that OWNER-OPERATOR has title to or is authorized to
contract the Equipment and services to CARRIER. Upon initiation of this Agreement with the OWNER-OPERATOR,
CARRIER shall furnish to OWNER- OPERATOR a verification form for Equipment to be contracted, which shall
constitute the receipt required by 49 C.F.R.§
376.11(b). Upon termination of this Agreement, OWNER-OPERATOR shall execute a similar form terminating the
availability of the Equipment; provided, however, that the Agreement and CARRIER’s obligations thereunder shall expire
upon the written notice of termination regardless of whether OWNER-OPERATOR submits the form terminating the
availability of the equipment as required by this provision.
Year
Make
Serial No.
Unit #
2.
DURATION OF AGREEMENT AND TERMINATION. This Agreement shall begin on the date set forth
above. Either party may terminate this Agreement for any reason by giving three (3) day’s written notice to that effect
to the other party either personally, by mail, or by fax machine at the address or fax number shown at the end of this
Agreement. The ability of either party to terminate this Agreement shall in no way be interpreted as an at-will
employment provision and shall not otherwise affect OWNER-OPERATOR’s status as an independent contractor
under this Agreement. The effective date and time of termination shall be as set forth in the written notice or the
verification form for Equipment issued by OWNER-OPERATOR, whichever date is earlier. OWNER-OPERATOR shall,
upon the termination of this Agreement, remove all CARRIER identification from the Equipment and return it to
CARRIER, via hand delivery or certified mail, together with all of CARRIER’s property, paperwork, load securement
equipment and freight, to CARRIER’s nearest terminal. If OWNER-OPERATOR fails to return CARRIER’s property
or freight to CARRIER or remove and return all CARRIER identification from the Equipment upon termination of this
Agreement, OWNER-OPERATOR shall pay CARRIER, all collections costs incurred by CARRIER, including reasonable
attorney fees, and CARRIER may pursue all other remedies allowed by law or authorized in the Agreement against
OWNER-OPERATOR.
3.
COMPENSATION. It is expressly understood and agreed that OWNER-OPERATOR’s compensation shall be as
set forth in Appendix A, and such compensation shall constitute the total compensation for everything furnished,
provided, or done by OWNER-OPERATOR in connection with this Agreement, including driver’s services. Although
CARRIER shall use reasonable efforts to make shipments available to OWNER-OPERATOR for transportation during
the term of this Agreement, OWNER- OPERATOR acknowledges and agrees that CARRIER does not guarantee
any specific number of shipments or amount of revenue to OWNER-OPERATOR during the term of this Agreement.
4.
SETTLEMENT PERIOD.
At any time during which OWNER-OPERATOR participates in CARRIER’s
Administrative Services program as set forth in Section 3(c) to Appendix A, CARRIER shall settle with OWNEROPERATOR with respect to services provided under this Agreement within fifteen (15) calendar days of OWNEROPERATOR’s completion of the services at issue, conditioned upon OWNER-OPERATOR’s submission of properly
completed logs if and as required by the U.S. Department of Transportation (“DOT”). If OWNER-OPERATOR
does not participate in CARRIER’s Administrative Charge program as set forth in Section 3(c) to Appendix A, CARRIER
shall settle with OWNER-OPERATOR with respect to services provided under this Agreement within fifteen (15)
calendar days after OWNER-OPERATOR’s submission, in proper form, of those documents necessary for CARRIER to
secure payment from its customers, including the signed freight bill, delivery receipt or bill of lading, proof of accessorial
services and properly completed logs i f a n d as required by the U.S. Department of Transportation (“DOT”).
Upon request of OWNER-OPERATOR, CARRIER shall provide OWNER-OPERATOR with a copy of the
documents necessary to calculate the compensation paid to CARRIER by CARRIER’s customers for shipments
handled by OWNER-OPERATOR. OWNER-OPERATOR may examine CARRIER’s tariffs, or other contracts or
documents, if any, from which charges and rates are computed; provided, however, only that information that would
Page 17 of 43
appear on a rated freight bill need be disclosed by CARRIER. CARRIER shall have the right to review all of OWNEROPERATOR’s documents and records relating to the use of the Equipment and the services provided under this
Agreement, and OWNER-OPERATOR agrees to provide CARRIER with access to such documents and records upon
reasonable notice. OWNER-OPERATOR must give CARRIER written notice of any dispute regarding amounts paid or
not paid by CARRIER, which notice must be received by CARRIER within ninety (90) days of payment by CARRIER of
the settlement giving rise to the dispute. The written notice must be sent to CARRIER’s Compliance Department at PO
Box 290279, Nashville, TN 37229-0279 in order to be effective.
FAILURE TO PROVIDE NOTICE AS
REQUIRED HEREIN WITHIN THE TIMEFRAME REQUIRED HEREIN WILL RESULT IN WAIVER OF ANY CLAIM
OWNER-OPERATOR MAY HAVE WITH RESPECT TO ANY SUCH PAYMENT OR FAILURE TO PAY. With respect
to final settlement upon termination of this Agreement, the failure on the part of OWNER-OPERATOR to remove and
return to CARRIER all identification devices of CARRIER or a letter certifying their removal shall entitle CARRIER to
withhold any payments owed to OWNER-OPERATOR, until such obligation is met.
5.
CHARGE BACK. CARRIER shall charge back to OWNER-OPERATOR at the time of payment or settlement,
any liability or expense CARRIER has incurred or paid that, under this Agreement or any addendum to this Agreement,
OWNER-OPERATOR is obligated to bear.
Such expenses shall be deducted from the amount of OWNEROPERATOR’s compensation and shall include those expenses set forth in Appendix A of this Agreement.
The
amount of each item to be charged back to OWNER- OPERATOR shall be disclosed in Appendix A or elsewhere in
this Agreement or any addendum thereto. CARRIER shall provide OWNER-OPERATOR written itemization and
documentation of all charge backs where such documentation is necessary to verify the validity of the charge.
6.
INSURANCE. The respective obligations of the parties shall be as set forth in Appendix B. CARRIER shall
maintain public liability, property damage and cargo insurance in such amounts as are required by the DOT and
applicable state regulatory agencies.
CARRIER shall maintain insurance coverage for the protection of the
public pursuant to 49 U.S.C. § 13906. CARRIER’s possession of legally required insurance shall in no way restrict
CARRIER’s right of indemnification from OWNER- OPERATOR as provided under this Agreement.
7.
COMPLIANCE WITH PERTINENT LAWS AND REGULATIONS BY OWNER-OPERATOR.
(a)
Drivers. OWNER-OPERATOR shall provide competent drivers who meet CARRIER’s minimum driver
qualification standards and all of the requirements of the DOT, including but not limited to, familiarity and
compliance with state and federal motor carrier safety laws and regulations. Where required by law,
OWNER-OPERATOR and OWNER-OPERATOR’s drivers shall obtain and maintain commercial driver
licenses. Any and all licenses, commercial or otherwise required to perform the services hereunder,
must remain valid so long as OWNER-OPERATOR and/or OWNER-OPERATOR’s drivers continue
to perform services pursuant to this Agreement. The parties agree that CARRIER shall have the right
to disqualify any driver provided by OWNER-OPERATOR in the event that the driver is found to be
unsafe, unqualified pursuant to federal or state law, in violation of CARRIER's minimum qualification
standards, unprofessional, or in violation of any policies of CARRIER or CARRIER’s customers.
Upon a driver’s disqualification by CARRIER, OWNER-OPERATOR shall be obligated to furnish another
competent, reliable and qualified driver that meets the minimum qualification standards established by
CARRIER.
(b)
Paperwork Requirements. OWNER-OPERATOR shall submit to CARRIER, on a timely basis, all
driver logs and supporting documents (including original toll receipts for CARRIER’s reproduction),
physical examination certificates, accident reports, and any other required data, documents or reports.
As required by 49 C.F.R. § 376.12(i), CARRIER will keep the original of this Agreement with a copy to
be maintained by OWNER-OPERATOR, and a second copy to be carried in the Equipment during the
term of this Agreement.
(c)
Shipping Documents. OWNER-OPERATOR agrees that all bills of lading, waybills, freight bills,
manifests, or other papers identifying the property carried on the Equipment shall be those of CARRIER,
or as authorized by CARRIER, and shall indicate that the property transported is under the
responsibility of CARRIER or a carrier with which the Equipment has been subcontracted.
(d)
Drug and Alcohol Testing. OWNER-OPERATOR and, in the event OWNER-OPERATOR is not the
sole operator of the Equipment, OWNER-OPERATOR’s drivers, shall comply with CARRIER’s Drug and
Alcohol Policy, including participation in CARRIER’s random drug and alcohol testing program, and any
addendums or revisions thereto. Timing and frequency of screens may vary depending on the customers
served by OWNER-OPERATOR. Likewise, OWNER-OPERATOR will submit to a background check as
required by various customers of CARRIER.
(e)
Safe Operations. OWNER-OPERATOR agrees to operate the Equipment in a safe and prudent
manner at all times so as to avoid endangering the public, the driver, and/or the property being
Page 18 of 43
transported and in accordance with the laws of the various jurisdictions in which the Equipment will be
operated and pursuant to the operating authorities of CARRIER, and in accordance with all rules related
to traffic safety, highway protection and road requirements. Moreover, OWNER-OPERATOR agrees
that all drivers and/or workers employed by OWNER-OPERATOR will comply with the terms of this
Agreement, including the requirement of safe operations, while operating the Equipment on behalf of
OWNER-OPERATOR. OWNER-OPERATOR agrees that any driver utilized by OWNER-OPERATOR
will comply with CARRIER’s policies and procedures and any subsequent revisions thereto, which will be
provided by CARRIER.
8.
OPERATIONAL EXPENSES.
(a)
Operating Expenses. OWNER-OPERATOR shall, at its sole cost and expense, provide all the
Equipment ready to operate and fully roadworthy, including the necessary licenses, permits, cab
cards, state base plates and shall furnish all necessary oil, fuel, tires, and other parts, supplies and
equipment necessary or required for the safe and efficient operation and maintenance of the Equipment,
including repairs for the operation of such Equipment. OWNER-OPERATOR shall pay all expenses
incident to the operation of the Equipment, including, but not limited to, empty mileage, lumper expenses,
highway use taxes, weight taxes, state property or indefinite situs taxes, fuel taxes, registration fees, ferry
and toll charges, and detention and accessorial charges not collected by CARRIER because of OWNEROPERATOR’s failure to provide the required documentation.
(b)
Maintenance and Inspection. OWNER-OPERATOR, at its sole cost and expense, shall maintain the
Equipment in safe condition and in complete compliance with all laws and regulations of the states in
which OWNER-OPERATOR operates and, as applicable, the DOT. In order to ensure compliance with
all applicable DOT regulations, OWNER-OPERATOR shall, at its sole cost and expense, make the
Equipment available for inspection by CARRIER upon reasonable request by CARRIER.
OWNER-OPERATOR shall, at its sole cost and expense, have the Equipment inspected annually, as
required by 49 C.F.R. § 396.17, at CARRIER's maintenance facility or at another maintenance
facility which CARRIER may, in its sole discretion, authorize. OWNER-OPERATOR shall, as
directed by CARRIER, forward to CARRIER all inspection, maintenance and repair records for the
Equipment.
(c)
Fines. OWNER-OPERATOR or its drivers (as professional drivers engaged in a separate and distinct
profession) agree to pay all fines, including but not limited to parking and traffic fines and penalties,
imposed for violation of any law or regulation by the state or any locality in which OWNER-OPERATOR
operates, the DOT, where such violation results, at least partially, from the acts or omissions of OWNEROPERATOR.
9.
UNIFORMS.
In order to perform the services provided for under this Agreement, it will be necessary for
OWNER- OPERATOR to enter upon the premises of customers of CARRIER. In order to gain access to such
facilities, help ensure the safety and security of such facilities, CARRIER’s customers may require OWNEROPERATOR to wear a uniform and/or a photo identification badge, which badge may indicate that the OWNEROPERATOR is “leased to” CARRIER, or may otherwise bear CARRIER’s or the customer’s name or logo. Such
uniform and/or photo identification badge shall be removed while not performing services pursuant to this
Agreement. The OWNER-OPERATOR shall have the option of purchasing shirts or caps with the Express Courier
logo on it from CARRIER or from another source. If OWNER-OPERATOR elects to purchase any part of the uniform
from CARRIER, OWNER-OPERATOR’s purchases shall be deducted from the OWNER-OPERATOR’s settlement(s).
10.
COMMUNICATION EQUIPMENT.
Given the time sensitive nature of CARRIER’s business, all OWNEROPERATORS must have a communication device which interface’s with the CARRIER’s operating system.
The
OWNER-OPERATOR may purchase its own equipment; however, it must be demonstrated to the satisfaction of
CARRIER that the device has coverage in the area to be served and provides the functionality needed prior to entering
this Agreement. The OWNER-OPERATOR also has the option to rent the equipment from the CARRIER on a weekly
basis. The cost (as stated in Appendix A) shall be charged back to OWNER-OPERATOR.
11.
CARGO CLAIMS. OWNER-OPERATOR shall immediately report all cargo claims, including all shortages,
overages or other exceptions to the cargo, to CARRIER. CARRIER reserves the right to investigate all paid cargo
claims, including but not limited to, delays, shortages, mis-deliveries, and claims related to lost, damaged or
contaminated loads, arising out of, or in connection with, OWNER-OPERATOR's services to determine if OWNEROPERATOR's actions or omissions resulted in, or contributed to, the cargo claim. If it is determined, in the sole
discretion of CARRIER, that OWNER-OPERATOR's actions or omissions resulted in, or contributed to, the cargo
claim, then CARRIER shall: a) charge back OWNER-OPERATOR for the first $250 of the cargo claim in the event
that OWNER-OPERATOR has elected to participate in CARRIER’s cargo liability limiter program (which election can be
made in Appendix A;or, b) charge back to OWNER-OPERATOR the full amount of any such claim in the event
OWNER- OPERATOR has not elected not elected to participate in CARRIER’s cargo liability limiter program.
Page 19 of 43
Before deducting any cargo claim from OWNER-OPERATOR’s compensation, CARRIER shall provide OWNEROPERATOR with a written explanation and itemization for each such claim.
12. ACCIDENTS AND CLAIMS. OWNER-OPERATOR shall immediately report any accident or potential claim to
CARRIER involving operations under this Agreement. OWNER-OPERATOR and its drivers shall cooperate fully with
CARRIER with respect to any legal action, regulatory hearing or other similar proceeding arising from the operation of
the Equipment, the relationship created by this Agreement or the services performed hereunder. OWNEROPERATOR shall, upon CARRIER’s request and at OWNER-OPERATOR’s sole expense, provide written reports or
affidavits, attend hearings and trials and assist in securing evidence or obtaining the attendance of witnesses.
OWNER-OPERATOR shall provide CARRIER with any assistance as may be necessary for CARRIER or CARRIER’s
representatives or insurers to investigate, settle or litigate any accident, claim or potential claim by or against CARRIER.
13. HOLD HARMLESS. Except to the extent that CARRIER is able to recover for OWNER-OPERATOR’s acts or
omissions under the insurance policies maintained by OWNER-OPERATOR hereunder, OWNER-OPERATOR agrees
to defend, indemnify and hold harmless CARRIER from any direct, indirect and consequential loss, damage, fine,
expense, including reasonable attorney’s fees, action, claim for injury to persons, including death, and damage to
property which CARRIER may incur arising out of or in connection with the operation of the Equipment, OWNEROPERATOR’s obligations under this Agreement, or any breach by OWNER-OPERATOR of the terms of this
Agreement. This provision shall remain in full force and effect both during and after the termination of this Agreement.
The foregoing notwithstanding, in the event that OWNER-OPERATOR participates in CARRIER’s Auto Liability
Indemnity program and maintains insurance complying with all requirements of such program as set forth in Appendix
B: (i) OWNER- OPERATOR shall have no liability to CARRIER for loss or damage in excess of the full policy limits of
OWNER- OPERATOR’s auto liability insurance; and (ii) CARRIER will hold harmless and indemnify OWNEROPERATOR, from any and all claims brought by third parties relating to or arising from any accident actually covered by
OWNER-OPERATOR’s automobile liability insurance, including claims by CARRIER’s insurers.
14.
CARRIER RESPONSIBILITIES.
(a)
Exclusive Possession and Responsibility. The Equipment shall be for CARRIER’s exclusive
possession, control, and use for the duration of this Agreement. As such, and as required by federal law,
the OWNER-OPERATOR shall not operate the Equipment for any other motor carrier without prior
written consent from CARRIER. CARRIER shall assume complete responsibility for the operation of
the Equipment for the duration of this Agreement. This subparagraph is set forth solely to conform
to DOT regulations and shall not be used for any other purposes, including any attempt to classify
OWNER-OPERATOR as an employee of CARRIER. Nothing in the provisions required by 49
C.F.R. § 376.12(c)(1) is intended to affect whether OWNER-OPERATOR or its drivers are an
independent contractor or an employee of CARRIER. An independent contractor relationship may exist
when a carrier complies with 49 U.S.C. § 14102 and attendant administrative requirements. The
foregoing notwithstanding, OWNER-OPERATOR may haul on behalf of other motor carriers during the
term of this Agreement, provided that OWNER-OPERATOR obtains CARRIER’s written permission to
enter into a trip lease, and provided further that OWNER- OPERATOR removes all identification from the
Equipment identifying CARRIER prior to beginning operations on behalf of any other carrier.
(b)
Identification of Equipment.
CARRIER shall identify the Equipment in accordance with the
requirements of the DOT and appropriate state regulatory agencies. CARRIER shall have the right to
place and maintain on the Equipment CARRIER’s name and any lettering, advertisement, slogans or
designs as CARRIER may choose.
OWNER-OPERATOR shall remove such identification at the
termination of this Agreement or while operating such Equipment for any purpose other than conducting
CARRIER’s business. At its discretion, OWNER-OPERATOR may have the identification permanently
painted on the Equipment. OWNER-OPERATOR further agrees to keep the Equipment in clean
appearance and identified as described herein, at its sole cost and expense. CARRIER agrees that
OWNER-OPERATOR may display OWNER-OPERATOR’s name and address on the Equipment where
required
by
applicable
state
law.
Page 20 of 43
(c)
Owner-Operator Not Employee Of Carrier.
It is expressly understood and agreed that OWNEROPERATOR is an independent contractor for the Equipment and driver services provided pursuant to this
Agreement. OWNER-OPERATOR shall not be considered, whether under the provisions of this
Agreement or otherwise, as having the status of an employee of CARRIER for any purpose whatsoever,
including but not limited to, federal, state or local tax purposes, and OWNER-OPERATOR shall not be
entitled to participate in any plans, arrangements or distributions the CARRIER may make in connection
with any pension, stock, bonus, profit sharing or similar benefits for CARRIER’s employees. Moreover,
OWNER-OPERATOR is not covered by unemployment insurance or workers’ compensation provided
by CARRIER, and OWNER-OPERATOR has no right to nor will OWNER-OPERATOR seek benefits or
any form of payment from or through CARRIER under state unemployment coverage or workers’
compensation. OWNER-OPERATOR agrees to defend, indemnify and hold CARRIER harmless for
any claims, suits, or actions, including reasonable attorney’s fees in protecting CARRIER’s interests,
brought by employees, any union, the public, or state or federal agencies, arising out of the operation
of the Equipment or the providing of driver services under this Agreement. CARRIER is concerned
only with the result achieved, and not the method used; therefore, OWNER- OPERATOR is free to select
his/her own routes, as well as the sequence of deliveries so long as applicable customer requirements
are met. OWNER-OPERATOR has the express right to accept or reject any assignment(s) from
CARRIER and may advertise is/her services to other competitive companies. OWNER-OPERATOR
also agrees to provide necessary documentation and apply for certification of its independent contractor
status where mandated by applicable state law. OWNER- OPERATOR hereby assumes full control and
responsibility for the selection, training, hiring, setting of grooming and dress standards, disciplining,
discharging, setting of hours, wages and salaries, providing for unemployment insurance, state and
federal taxes, fringe benefits, workers’ compensation, adjustment of grievances, all acts and omissions,
and all other matters relating to or arising out of OWNER-OPERATOR’s employment or use of drivers
and laborers, and any and all other employees or agents of OWNER-OPERATOR that OWNEROPERATOR may provide or use to perform any aspect of this Agreement. OWNER- OPERATOR shall
be solely responsible for complying with any and all state and federal laws, rules and regulations that may
be applicable to the terms and conditions of employment of OWNER-OPERATOR’s employees or
applicants for employment, including, without limitation, compliance with the Federal Fair Credit Reporting
Act; verification of immigration and naturalization status; proof of proper taxpayer identification number;
proof of highway use tax being currently paid when the OWNER- OPERATOR purchases its license;
proof of payment of income; unemployment; Medicare and other state and federal payroll taxes; and,
other required withholdings for OWNER-OPERATOR’s employees.
OWNER-OPERATOR further
expressly acknowledges, understands, and agrees that OWNER-OPERATOR is responsible for the
payment of estimated Social Security taxes, along with state and federal income taxes, and that such
Social Security tax is higher than the Social Security tax that OWNER-OPERATOR would pay if he or she
were an employee of CARRIER, and that the services performed by OWNER- OPERATOR for
CARRIER, pursuant to this Agreement, is not work covered by the unemployment laws of any state,
including Georgia. OWNER-OPERATOR’s performance of these responsibilities shall be considered
proof of its status as an independent contractor in fact. Proof of such control and responsibility shall be
submitted by OWNER-OPERATOR to CARRIER as required by CARRIER and may include, but not be
limited to, proof of highway use tax being currently paid, proof of income tax being currently paid, and
proof of payment of payroll tax for OWNER-OPERATOR’s drivers. For the purposes of this section, the
term OWNER-OPERATOR refers to the owner of the Equipment as well as drivers that may be
operating the Equipment on behalf of the owner. As required by law, CARRIER agrees to file information
tax returns (Form 1099) on behalf of OWNER-OPERATOR if OWNER-OPERATOR is paid more than the
statutory
amount
in
compensation
during
a
calendar
year.
Page 21 of 43
15.
BREACH. Notwithstanding anything to the contrary in this Agreement, this Agreement may be
terminated, at any time, by either party in the event of a material breach by the other of any term or obligation
contained in this Agreement. In the event of a breach and when practicable, written notice shall be served upon the
breaching party, notifying such party of the breach and the termination of the Agreement and reason therefore. If,
in CARRIER’s judgment, OWNER-OPERATOR has subjected CARRIER to liability because of OWNEROPERATOR’s acts or omissions, CARRIER may take possession of the shipment entrusted to OWNER-OPERATOR
and complete performance. In such event, OWNER-OPERATOR shall waive any recourse against CARRIER for
such action and OWNER-OPERATOR shall reimburse CARRIER for all direct or indirect costs, expenses, or
damages, including attorney’s fees, incurred by CARRIER as a result of CARRIER’s taking possession of the
shipment and completing performance.
16.
OWNER-OPERATOR NOT REQUIRED TO PURCHASE PRODUCTS, EQUIPMENT, OR
SERVICES FROM CARRIER. OWNER-OPERATOR is not required to purchase or rent any products, equipment,
or services from CARRIER as a condition of entering into this Agreement. In the event OWNER-OPERATOR elects
to purchase or rent equipment from CARRIER or from any third party, for which the purchase or rental contract gives
CARRIER the right to make deductions from OWNER- OPERATOR’s settlement, then the parties mutually agree to
attach and incorporate each such contract, specifying all terms thereof, to this Agreement as a separate addendum.
17.
PASSENGER AUTHORIZATION.
In accordance with customer requirements regarding security,
OWNER-OPERATOR shall not allow any passengers to ride in the Equipment unless authorized in writing by
CARRIER as required by law. Before passenger authorization will be given by CARRIER, OWNER-OPERATOR
(or its driver) and the passenger requesting authorization shall submit a fully executed Passenger Authorization and
Release of Liability form to CARRIER for prior approval.
18.
LOADING AND UNLOADING. In the event the shipper or consignee does not assume loading and
unloading responsibilities, OWNER-OPERATOR shall be responsible for the loading or unloading of property
transported on behalf of CARRIER at OWNER-OPERATOR’s expense unless otherwise specified in Appendix A.
19.
CONFIDENTIALITY.
OWNER-OPERATOR hereby recognizes and acknowledges that any list of
CARRIER’s customers, as it may exist now or from time to time, is a valuable, special and unique asset of the
business of CARRIER. OWNER-OPERATOR agrees, during and after the term of this Agreement, not to disclose the
list of CARRIER’s customers or any part thereof to any person, firm, corporation, association, or other entity for any
reason or purpose whatsoever without CARRIER’s prior written consent. OWNER-OPERATOR agrees to preserve
as “Confidential Matters”, all trade secrets, know how and information relating to CARRIER’s business, forms,
processes, developments, sales and promotional systems, prices and operations, which information may be obtained
from tariffs, contracts, freight bills, letters, reports, disclosures, reproductions, books, records, or other contractors,
and other sources of any kind resulting from this Agreement. OWNER-OPERATOR agrees to regard such
Confidential Matters as the sole property of CARRIER, and shall not publish, disclose or disseminate the same to
others without the written consent of CARRIER. In the event of any breach or threatened breach by OWNEROPERATOR of the provisions of this paragraph, CARRIER shall be entitled to an injunction, restraining OWNEROPERATOR from disclosing, in whole or in part, the list of CARRIER’s customers, and all other Confidential
Matters. OWNER-OPERATOR agrees that CARRIER will be irreparably damaged in the event of any breach of
this provision by OWNER-OPERATOR. Accordingly, in addition to any other legal or equitable remedies that may be
available to CARRIER, OWNER-OPERATOR agrees that CARRIER will be able to seek and obtain immediate
injunctive relief in the form of a temporary restraining order without notice, preliminary injunction, or permanent
injunction against OWNER-OPERATOR to enforce this confidentiality provision. CARRIER shall not be required to
post any bond or other security and shall not be required to demonstrate any actual injury or damage to obtain
injunctive relief from the courts. Nothing hereunder shall be construed as prohibiting CARRIER from pursuing any
remedies available to CARRIER at law or in equity for such breach, including the recovery of monetary damages from
OWNER- OPERATOR.
20.
BENEFIT AND ASSIGNMENT. This Agreement shall be binding upon and inure to the benefit of the
parties to this Agreement and their respective successors. OWNER-OPERATOR may not assign or subcontract all
or a portion of its obligations to another party without the prior written consent of OWNER-OPERATOR.
21.
NOTICE. All notice provisions of this Agreement shall be in writing delivered personally, by postage
prepaid, first class mail, or by facsimile machine to the addresses or fax number shown at the end of this Agreement.
22.
NON-WAIVER. The failure or refusal of either party to insist upon the strict performance of any
provision of this Agreement, or to exercise any right in any one or more instances or circumstances shall not be
construed as a waiver or relinquishment of such provision or right, nor shall such failure or refusal be deemed a
customary practice contrary to such provision or right.
Page 22 of 43
23.
SEVERABILITY. If any Agreement or its appendices is deemed invalid for any reason whatsoever,
the Agreement shall be void only as to such provision, and this Agreement shall remain otherwise binding between
the parties. Any provision voided by operation of the foregoing shall be replaced with provisions which shall be as
close as the parties’ original intent as permitted under applicable law.
24.
GOVERNING LAW AND CHOICE OF FORUM. This Agreement is to be governed by the laws of the
United States and of the State of Tennessee, without regard to any choice of law rules, and CARRIER and
OWNER-OPERATOR hereby consent to the jurisdiction of the state and federal courts of Tennessee.
25.
COMPLETE AGREEMENT. This Agreement, including any Appendices attached, constitutes the
sole, entire, and existing agreement between the parties herein, and supersedes all prior agreements and
undertakings, oral and written, expressed or implied, or practices, between the parties, and expresses all obligations
and restrictions imposed on each of the respective parties during its term, except those specifically modified or
changed by mutual written agreement between CARRIER and OWNER-OPERATOR.
IN WITNESS WHEREOF, CARRIER and OWNER-OPERATOR hereby sign this Agreement as of the date stated above.
CARRIER: Express Courier International, Inc.
Owner-Operator
Address: 238 Bedford Way
Address:
Franklin
City
TN
State
37064
Zip
City
Fax:
Fax:
By:
Phone:
State
Zip
Cell Phone:
Printed Name
Email:
FEIN or SSN:
By:
Printed Name:
Page 23 of 43
RECEIPT FOR AVAILABILITY OF CONTRACTED VEHICLE(S)
Contracted from OWNER-OPERATOR the vehicle or vehicles described in this Agreement.
Equipment inspected at
20
at
:
o’clock
By:
.M.
on
_,
(CARRIER Representative)
Printed Name
Page 24 of 43
Appendix A
OWNER-OPERATOR’s Compensation
(Percentage of Revenue)
1. SHARE OF REVENUE.
Unless otherwise agreed to in writing between the parties, CARRIER shall pay OWNEROPERATOR a share of the revenue which will be based upon the vehicle size used with exceptions as noted:
2.
a)
For hauling of loads tendered by CARRIER: The percentage of Adjusted Gross Revenue set forth in the
Commission Percentage Table attached hereto as Appendix C shall by paid for pickups and deliveries
accomplished by OWNER-OPERATOR with Equipment pursuant to this Agreement.
b)
The foregoing notwithstanding, the Parties understand and agree that in certain circumstances CARRIER
may enter into special pricing arrangements with its customers pursuant to which it would be inequitable
between the Parties to pay OWNER-OPERATOR the rates contained in Appendix C. In those situations,
CARRIER and OWNER-OPERATOR will enter into a signed Settlement Addendum prior to dispatch of
the relevant movement that will govern the rate to be paid for the moves referenced in such Settlement
Addendum. Any such Settlement Addendum shall be considered a part of this Agreement and shall
continue in effect for all loads between the points stated therein unless revised in writing by a subsequent
Settlement Addendum or terminated by written agreement of the Parties.
c)
Adjusted Gross Revenue. AGR shall mean all revenue received by CARRIER from the shippers,
consignees, or other carriers for commodities hauled by OWNER-OPERATOR under this Agreement,
including fuel-related or other surcharges, reduced by: (1) any and all expenses attributed to accessorial
services paid to a third party or to OWNER-OPERATOR by CARRIER; (b) the amount paid to any third
party by CARRIER in relation to movement of the load, including without limitation, amounts paid to other
contractors as a pro-rata payment for their participation in the movement of a load; (c) any amount paid by
CARRIER to interline or augmenting carriers; (d) any warehouse or storage charges; (e) any revenue
received by CARRIER as an excess value or insurance charge on high value shipments; (f) all incentives,
discounts or commissions given to CARRIER’s customers or other third parties.
d)
Fuel Surcharges. CARRIER shall pay OWNER-OPERATOR fuel surcharges listed in the CARRIER’S
“Fuel Surcharge Program” which is hereby incorporated by reference as an addendum to this Agreement
e)
Accessorial Service Charges. OWNER-OPERATOR shall be paid a percentage of all delivery related
expenses and collected accessorial service charges, including detention, loading/unloading, equipment
order not used, reconsignment and diversion, repositioning, layover, and stop-off charges. The payment
percent will be based on the current Commission Percentage Table for vehicle sizes as set forth in
Appendix C.
PAY-CARD. Payment from CARRIER to OWNER-OPERATOR will be made via a Pay-Card whereby payment is
“loaded” onto a pay-card issued to OWNER-OPERATOR by a third party vendor (“Vendor”). Use of the Pay-Card
to receive payment is mandatory and by entering into this Agreement, OWNER-OPERATOR consents to
receiving payments via the Pay-Card issued by the Vendor. There are fees related to the use of the Pay-Card,
but those fees are neither paid nor owed to CARRIER. The Vendor offers one free transaction immediately
following loading of a payment onto the Pay-Card, and OWNER-OPERATOR can take advantage of the free
transaction in order to transfer funds from the card to a traditional bank account in order to avoid paying additional
fees to the Vendor. Vendor requires that OWNER-OPERATOR sign a Pay-Card Consent Form, and may also
require that OWNER-OPERATOR sign a Cardholder Agreement.
Page 25 of 43
3. CHARGE BACK ITEMS. The following items shall be charged back and deducted from OWNER-OPERATOR’s
compensation:
a)
Fixed Chargebacks. ONE TIME CHARGE BACK ITEMS AS NEEDED OR REQUESTED
Identification Badge (All OWNER-OPERATORs are responsible for obtaining at least one
badge from CARRIER or an alternative source. OWNER-OPERATORs electing the
administrative charge below are entitled to replacement badges at no additional cost.)
COST
$6.50 (per badge)
C.O.D. Charges (Customer payments collected and retained by OWNER-OPERATOR)
Fines and Penalties
Uniforms (Initial if Electing
)
Actual
Actual
Actual
Blood Spill Clean-Up Kits
Actual
Coolers
Actual
Handy Map
Actual
Cargo Claim (if OWNER-OPERATOR does not participate in cargo liability limiter program) Actual
Cargo Claim (if OWNER-OPERATOR participates in CARRIER’s cargo liability limiter
program)
First $250
OWNER-OPERATOR agrees that CARRIER may charge back to OWNER-OPERATOR any other
expenses or cost incurred by CARRIER for which OWNER-OPERATOR is responsible for under this
Agreement or as otherwise agreed to by the parties. OWNER-OPERATOR hereby waives any
objection to any charge back item unless OWNER-OPERATOR notifies CARRIER of OWNEROPERATOR’s disagreement with such charge back within thirty (30) days of the charge back.
b)
Tiered Chargebacks. The following items will likewise be charged back each week, with the amount of
the chargeback determined by the OWNER-OPERATOR’s average weekly gross commission in the month
preceding such chargeback. As such, at the beginning of the month, OWNER-OPERATOR will be
assigned to a tier, based on the process set forth herein, and any chargebacks from the chart below made
during such month will be for the amount set forth in the applicable tier. For purposes of determining the
average weekly gross commission for the preceding month, CARRIER will add the total gross commission
(i.e., pre-chargeback commission) of the OWNER-OPERATOR for all payments made by CARRIER during
the preceding calendar month, and divide that total by the number of payments made by CARRIER during
the preceding calendar month. That total will be compared against the chart below to determine the
applicable tier.
For new OWNER-OPERATORs for which there is no established payment history,
CARRIER will, in its sole discretion, assign the OWNER-OPERATOR to a tier during OWNEROPERATOR’s first month of operation. If, after the first calendar month of operation (whether a partial or
full month), it turns out the OWNER-OPERATOR was assigned to the wrong tier, CARRIER shall pay a
refund any overpayment, or OWNER-OPERATOR will reimburse CARRIER for any underpayment, as
applicable.
Page 26 of 43
Item
Tier 1
Tier 2
Tier 3
Tier 4
Occupational Accident Insurance
$1,000,000 Coverage (See Appendix
B for details and to elect)
$14.50
$27.50
$27.50
$27.50
Cargo Liability Limiter Program Per
Driver (See Appendix B for details)
(Initial if Electing
)
$4.00
$4.50
$5.00
$5.50
Auto Liability Indemnity Per Driver
(See Appendix B for details)
(Initial if Electing
)
$4.50
$5.00
$6.50
$7.00
$5.50
$17.00
$21.00
$24.00
$3.50
$5.00
$5.00
$5.00
$13.50
$19.00
$19.00
$19.00
3.25% of gross
weekly
compensation
3.25% of gross
weekly
compensation
2.00% of gross
weekly
compensation
1.15% of gross
weekly
compensation
Scanner (Initial if Electing
Per Unit
Pager (Initial if Electing
Per Unit
Nextel (Initial if Electing
Per Unit
Administrative Services
(Initial if Electing
)*
)
_)
)
*Maximum Charge is $45.00 per
week.
Tier
Average Gross Commission (per week) Range
1
$0.00-$249.99
2
$250.00-$499.99
3
$500.00-$799.99
4
$800.00 and up
c)
Administrative Services. OWNER-OPERATOR has the option, by electing above, of receiving certain
administrative services from CARRIER. Those services include provision of manifests, facilitation of drug
screens, facilitation of customer and/or government required background checks, obtaining an annual
motor vehicle report (“MVR”) in accordance with customer requirements, facilitation of customer required
training (e.g., biohazard and HIPPA), facilitating procurement of TSA required threat assessments, route
optimization, and ID badges.
At any time during which OWNER-OPERATOR participates in this
Administrative Services program, CARRIER shall settle with OWNER-OPERATOR with respect to
services provided under this Agreement within fifteen (15) calendar days of OWNER-OPERATOR’s
completion of the services at issue, conditioned upon OWNER-OPERATOR’s submission of properly
completed logs if and as required by the U.S. Department of Transportation (“DOT”). If OWNEROPERATOR does not participate in CARRIER’s Administrative Charge program CARRIER shall settle
with OWNER-OPERATOR with respect to services provided under this Agreement within fifteen (15)
calendar days after OWNER-OPERATOR’s submission, in proper form, of those documents necessary for
CARRIER to secure payment from its customers, including the signed freight bill, delivery receipt or bill of
lading, proof of accessorial services and properly completed logs as required by the U.S. Department
of Transportation (“DOT”). The provisions of this Section shall govern in the event of any inconsistency or
dispute with the provisions of the Agreement governing settlement period. If OWNER-OPERATOR is not
electing to receive Administrative Services from CARRIER, then OWNER-OPERATOR is responsible for
the following:
Page 27 of 43
i.
ii.
iii.
iv.
v.
vi.
vii.
OWNER-OPERATOR must supply route sheets and manifests in order to document daily pick-ups
and deliveries as required by CARRIER’s customers.
OWNER-OPERATOR must ensure that it and all of its drivers submit to a drug screen (at least 10
panels) from a vendor approved by CARRIER and provide the results to CARRIER. This 10 panel
minimum screen is in addition to, and not a substitute for, any drug screen required by applicable
motor carrier safety regulations (which require screening of drivers holding commercial driver
licenses).
OWNER-OPERATOR must provide, annually, a criminal background check of state, federal, and
local databases going back at least 10 years.
OWNER-OPERATOR must provide an annual MVR that is not more than a month old and that
includes a minimum years of history. In addition to this OWNER-OPERATOR must provide
additional MVR as required.(Customer, vendor or safety requirement applies here.)
OWNER-OPERATOR must obtain training with respect to HIPPA and Biohazard training from
customer approved sources, and provide proof of acceptable completion of such training to
CARRIER.
OWNER-OPERATOR must obtain either a Transportation Worker Identification Credential
(“TWIC”), Hazardous Material Endorsement to a commercial driver license, or other TSA-approval
alternative Security Threat Assessment (“STA”) credential and provide proof of such credential to
CARRIER.
OWNER-OPERATOR must route its own stops.
The undersigned parties agree to THIS APPENDIX as the latest date set forth below.
CARRIER:
OWNER-OPERATOR:
By:
By:
Printed Name
Printed Name
Date:
Date:
Page 28 of 43
Appendix B
INSURANCE
It shall be CARRIER’s responsibility, pursuant to federal and state law, to provide public liability and property damage
insurance for the Equipment at all times while the Equipment is being operated on behalf of CARRIER. However,
CARRIER’s possession of such insurance shall in no way affect CARRIER’s rights of indemnification against
OWNER-OPERATOR as provided for in this Agreement. OWNER-OPERATOR shall maintain, at its sole cost and
expense, the following minimum insurance coverages in support of its indemnity of CARRIER during the term of this
Agreement and, if applicable, pay CARRIER to assume its liability under the parameters as set forth in paragraph
1(a) and (b). below.
1.
AUTO LIABILITY.
a. OWNER-OPERATOR shall procure, carry and maintain auto liability insurance, which shall provide
coverage to OWNER-OPERATOR for bodily injury or death to any person in a minimum amount of
$100,000 or $300,000 minimum for any single occurrence or for damages to property in any single
occurrence of $100,000 or a combined single limit of no less than $300,000. Although CARRIER shall
have primary responsibility to provide insurance for the protection of the public, OWNER-OPERATOR’s
coverage shall be primary vis-à-vis CARRIER and shall show CARRIER as an additional insured of such
coverage.
OWNER-OPERATOR’s policy shall not contain any policy exclusions reasonably likely to
exclude coverage for OWNER-OPERATOR’s operations pursuant to this Agreement, including, but not
limited to, exclusions for business use.
b. OWNER-OPERATOR shall also pay, via settlement deduction, for participation in CARRIER’s Auto
Liability Indemnity (“ALI”) program.
This charge shall be for limitation of damages that OWNEROPERATOR may otherwise be responsible to CARRIER for in excess of the coverage otherwise
payable under OWNER-OPERATOR’s above-described auto liability insurance coverage. Charges for the
ALI program are set forth in Appendix A.
c. As an alternative to providing a certificate of auto liability insurance evidencing the coverage set forth in
section (a) above, and participation in the ALI program, OWNER-OPERATOR may provide CARRIER a
certificate of insurance evidencing commercial auto liability coverage in the amount of $1,000,000
combined single limit, showing CARRIER as an additional insured of such coverage. Although CARRIER
shall have primary responsibility to provide insurance for the protection of the public, OWNEROPERATOR’s coverage shall be primary vis-à-vis CARRIER.
2.
WORKERS’ COMPENSATION/OCCUPATIONAL ACCIDENT INSURANCE.
OWNER-OPERATOR shall
provide workers’ compensation insurance coverage for all its employees, agents and anyone driving the
Equipment in amount not less than statutory limits required by applicable state law. Other than in the state of CA,
CO, MA, NC, NJ, NV, or NY, if OWNER-OPERATOR is the sole owner and the sole and exclusive operator of the
vehicle that is driven exclusively by OWNER-OPERATOR under this Agreement, then OWNER-OPERATOR
may, as an alternative to obtaining workers’ compensation coverage, obtain an occupational accident insurance
policy that is acceptable to CARRIER or participate in an occupational accident program facilitated by CARRIER
for a weekly charge, per driver, as set forth in Appendix A. If OWNER-OPERATOR is otherwise is entitled to
obtain and rely upon occupational accident coverage as set forth above, OWNER-OPERATOR must obtain a
policy with limits of at least $1,000,000. If OWNER-OPERATOR is based and/or resides in North Carolina, and if
CARRIER consents, OWNER-OPERATOR can elect to be covered by CARRIER’s workers’ compensation
insurance coverage, the mutually agreed cost of which will be charged back to OWNER-OPERATOR.
3.
CARGO INSURANCE. In addition to the insurance coverages required under this Agreement, it is OWNEROPERATOR’s responsibility to procure cargo insurance in amounts acceptable to CARRIER (no less than
$100,000 per vehicle with a deductible amount no greater than $250 per vehicle) or participate in CARRIER’s
cargo liability limiter program for a charge as set forth in Appendix A, pursuant to which OWNER-OPERATOR’s
cargo liability to CARRIER is limited to the first $250 per claim.
Page 29 of 43
4.
ACCEPTABILITY OF COVERAGE. OWNER-OPERATOR shall furnish to CARRIER written certificates
obtained from OWNER-OPERATOR’s insurance carrier showing that all insurance coverages required above
have been procured from and A.M. Best “B” rated company, are being properly maintained, and the premiums
therefore are paid, specifying the name of the insurance carrier, the policy number, the expiration date, naming
CARRIER as an additional insured (or for cargo coverage - loss payee), and further showing that written notice of
cancellation or modification of the policy shall be given to CARRIER at least thirty (30) days prior to such
cancellation or modification. OWNER-OPERATOR agrees to defend, indemnify and hold harmless CARRIER
from any direct, indirect and consequential loss, damage, fine, expense, including reasonable attorney fees,
actions, claim for injury to persons, including death, and damage to property which CARRIER may incur arising
out of or in connection with, OWNER-OPERATOR’s failure to maintain the insurance coverages required by this
Agreement. In addition, OWNER-OPERATOR, on behalf of its insurer, expressly waives all subrogation rights
against CARRIER, and, in the event of a subrogation action brought by OWNER-OPERATOR’s insurer, OWNEROPERATOR agrees to defend, indemnify and hold harmless CARRIER from such claim. OWNER-OPERATOR
may, at OWNER-OPERATOR’s notion, authorize CARRIER to facilitate, on OWNER-OPERATOR’s behalf, the
payment of insurance coverages via coverages pre-approved by CARRIER in accordance with the requirements
of this Agreement. OWNER-OPERATOR will be charged back for all CARRIER’s expense and cost of such
facilitation. In addition, upon failure herein, CARRIER is authorized but not required to obtain such insurance at
its expense and charge OWNER-OPERATOR all cost incurred by CARRIER in obtaining and facilitating payment
for such coverage on OWNER-OPERATOR’s behalf. OWNER-OPERATOR recognizes that CARRIER is not in
the business of providing or selling insurance, and any insurance coverage requested by OWNER-OPERATOR
from CARRIER is subject to all of the terms, conditions and exclusions of the actual policy issued by the
insurance underwriter. For policy(s) facilitated by CARRIER, CARRIER shall ensure that OWNER-OPERATOR is
provided with a certificate of insurance (showing the name of the insurer, the cost of insurance, the deductibles (if
any), the policy number, the type of insurance, and the effective dates of the insurance) for each insurance policy
under which the OWNER-OPERATOR selects coverage from the insurance underwriter, and CARRIER shall
provide OWNER-OPERATOR with a copy of each policy upon request by OWNER-OPERATOR.
CARRIER: EXPRESS COURIER
INTERNATIONAL, INC.
OWNER-OPERATOR:
By:
By:
Printed Name
Printed Name
Fax:
Title
Fax:
Address:
Address: 238 Bedford Way
City:
City: Franklin
State: TN
Zip: 37064
State:
Zip:
Phone:
Cell Phone:
FEIN or SSN:
Email:
Page 30 of 43
COVERAGE ADMINISTERED BY ECI BY DEDUCTION
OWNER-OPERATOR hereby requests CARRIER, through the insurance broker with pre-approved insurance programs, to obtain
for OWNER-OPERATOR the insurance coverages marked with OWNER-OPERATOR’s initials below. In the event OWNEROPERATOR elects such coverage, the following shall be considered the certificate of insurance which CARRIER is obligated to
provide to OWNER-OPERATOR.
Workers’ Compensation:
[or occupational accident if OWNER-OPERATOR is sole owner and operator of the vehicle]
Insurance Co.:
Policy No.:
Coverage Dates:
Amount of Coverage: $_
Current Cost to OWNER-OPERATOR: $
per unit of Equipment per month
Deductible for which OWNER-OPERATOR is liable: $
per occurrence
Occupational Accident Coverage:
Insurance Co.:
Policy No.:
Coverage Dates:
Amount of Coverage: $_
Current Cost to OWNER-OPERATOR: $
per unit of Equipment per month
Deductible for which OWNER-OPERATOR is liable: $
per occurrence
Minimum Coverage: Statutory [Minimum coverage for occupational accident based on CARRIER facilitated program
as minimum benefit limits]
Owner-Operator’s Signature
Print Name
Date
Page 31 of 43
Appendix C
COMMISSION PERCENTAGE TABLE
70% of AGR 14ft or Larger Box Truck
65% of AGR Extended Cargo Vans (2-3 ft extensions)
60% of AGR Cargo Vans and Covered Full-Size Pickup Trucks (must hold two 4’x4’x4’ skids or equivalent)
55% of AGR Minivans or Covered Small Pickup Trucks
50% of AGR Cars
45% of AGR Pickup Trucks without Topper - (contractors have 30 days to secure a Topper)
Page 32 of 43
Hepatitis B Vaccine Notice Form
Facility Location:
I understand that due to my occupational exposure to blood or other potentially infectious materials (OPIM), I may be at
risk of acquiring hepatitis B virus (HBV) infection.
I understand that without the vaccine, I am at risk of acquiring hepatitis B, a serous disease. I understand that as an
owner operator it is my responsibility to pay the cost of the vaccination.
By signing below, I acknowledge my receipt and review of this notice.
Owner Operator’s Name (Print)
Owner Operator’s Signature
Date
Page 33 of 43
Web Training Instructions
Instructions for viewing the HighQ online training seminar Medical Courier Training are listed below. This is an audio and
video program that you must follow along with the training manual. Begin by clicking on the link below:
https://www.323.livemeeting.com/cc/highqllc/view
•
•
•
Your Name:
Recording ID:
Recording Key:
1.
2.
3.
4.
Your full name
dotc
bbp
Click on View Recording.
Type in your email address and the name of your company.
Once again click on View Recording.
There will be two formats to choose from. Click on View beside Microsoft Live Office Replay.
(Note: You will need to use Microsoft Internet Explorer for your browser. Some browsers do not support these programs.)
This will take you through the seminar letting you stop, pause and replay if necessary. At the end of the training the HighQ
testing page will appear on your screen. If you are not taken directly to this testing page, please contact us at
start@highqllc.com. You can also log on directly to the test at http://www.highqllc.com/QuizMed.html.
Upon completion of your quiz, type in your full name and company then click Send.
It is recommended that you print a copy of your quiz results for your own records. If your results don’t email properly, you
can fax them to HighQ Training at 1-888-371-0863.
Keep your certificate of completion for your permanent records.
If you have any questions or problems logging on, please email HighQ Training at start@highqllc.com or call 724-749-4710,
extension #4.
Thank you, HighQ Training
Page 34 of 43
INDEPENDENT CONTRACTOR
OCCUPATIONAL ACCIDENT
ENROLLMENT FORM
Express Courier International,
Inc.
INSURED PERSON INFORMATION:
Last Name
CERTIFICATION
First Name
M.I.
Street
City
State
Zip
Contact Telephone Number(s)
Date of Birth
Social Security Number
Email address
Beneficiary Last Name
First Name
M.I.
Beneficiary Address
or
Relationship
Check box to have death benefits paid to my Estate
Start Date
Check One: Full time:
Driver Number
or Part time:
Location/Terminal:
Gallagher Transportation Services
I certify that all information in this Enrollment Form and other
enrollment documents is true and correct to the best of my
knowledge.
I hereby request occupational accident coverage
under the insurance program (“Occupational Accident Program”)
developed by Gallagher Transportation Services (“Gallagher”). I
verify that I am the independent contractor/driver named on this
Enrollment Form who is under contract to the facilitating motor
carrier on the date of this Enrollment Form. I verify that I am also
an independent contractor/driver under contract to the facilitating
motor carrier and understand that I am covered only while under
contract with the facilitating motor carrier. I have designated the
noted beneficiary in the event of my death.
I certify that I am under the age of 75 as of the date set forth
below my signature.
I understand and acknowledge that Arthur J. Gallagher Risk
Management Services, Inc. (“AJG”) is the insurance agent with
limited authority to procure the insurance coverage referenced in
this Enrollment Form. I also acknowledge that I have not sought
or received insurance advice from Gallagher or AJG on the
referenced insurance coverage as it applies to me and/or my
business needs.
I further understand and acknowledge that
compensation for the services described above is part of the cost
of the insurance coverage and not separately charged to me.
In accordance with my independent contractor operating
agreement, and as an addendum thereto, I authorize the
facilitating motor carrier to periodically deduct my insurance costs.
If such settlements (or other monies due me) are not sufficient to
cover the insurance costs, I will remit by certified check or money
order the outstanding insurance cost to Gallagher Transportation
Services, 2345 Grand Boulevard, Suite 400, Kansas City, MO
64108 within a ten (10) day period. Otherwise, I understand the
insurance underwriters may cancel this insurance coverage in
accordance with policy terms and conditions. I also understand
coverage will not automatically be reinstated if cancellation is
processed. I have read, understand and agree to the terms and
conditions on the reverse side of this Enrollment Form.
I agree that a photographic, facsimile or electronically signed copy
of the authorization is as valid as the original.
By signing below, I acknowledge that I may receive my
Occupational Accident Confirmation of Coverage electronically in
lieu of it being mailed to my residence. If I would prefer to receive
a paper copy, I will contact Gallagher Transportation Services at
800.279.7500 and request a copy.
Arthur J. Gallagher Risk Management Services, Inc.
Administrative Office:
2345 Grand Blvd., Suite 400
Kansas City, MO 64108
(800) 279-7500
(816) 329-0891 (Fax)
Occ.Acc Enrollment Form Edition 01.01.2011-Electronic
Transportationword/PolicyForms/T4OccAccEnrollmentFormElectronic01.10.2011.doc
Signed:
Date:
Page 1 of 2
TERMS AND CONDITIONS - Please read carefully
It is further understood and agreed:
1. Not Statutory Workers’ Compensation & Employers’
Liability: This coverage is NOT a statutory Workers’
Compensation and Employers’ Liability policy, and the
benefits under this coverage do not necessarily equal the
benefits which an individual might be eligible for
under statutory Workers’ Compensation. However, you
agree that in the event of an occupational accident, you
will look to the occupational accident coverage described
herein in lieu of seeking Workers’ Compensation coverage.
2. Assignment of Benefits: In the event benefits are
paid from the statutory Workers’ Compensation and
Employers’ Liability Policy of the facilitating motor carrier or
any similar policy becomes liable for such benefits, the
benefits which an Insured Person is entitled to under this
policy will be automatically assigned to the facilitating motor
carrier. In such event, you agree to the immediate
assignment to the facilitating motor carrier of all benefits
which you receive or would otherwise be payable to you or
any third party under the Occupational Accident Program.
3. Cost and Consent to Cost Change: You understand
that the insurance cost shown may include taxes, fees and
administrative expenses which you accept
and
acknowledge as part of the insurance cost. The insurance
underwriters reserve the right to change the rate by giving
written notice to you.
4. Evidence of Coverage:
Your state of principal
operations could require you to purchase Statutory
Workers’ Compensation, otherwise, the facilitating motor
carrier will accept coverage under the Occupational
Accident Program.
If you do not participate in the
Occupational Accident Program, you are required to have
on file a certificate of insurance for Statutory Workers’
Compensation or when allowed by law, an Occupational
Accident Certificate. Your insurance agent should provide
this information to the facilitating motor carrier.
You will be enrolled in the facilitated occupational accident
program until you provide proof of appropriate coverage.
At that time you will receive an adjustment in any costs
charged to you.
5. Termination: In the event your independent contractor
operating agreement with the facilitating motor carrier is
terminated for any reason by either party, the occupational
accident coverage will be cancelled effective the date of
the contract termination or the earliest date thereafter
allowed by law.
You should make arrangements to
replace coverage immediately.
6. Terms & Conditions: Coverage will be subject to all
policy terms, conditions and exclusions as detailed in the
Evidence of Insurance. The Insured Person must be
under age 75 to enroll in the Occupational Accident
Program.
7. Authorization of Settlement Deduction: You
authorize the facilitating motor carrier to deduct from your
settlement checks, funds, accruals or other compensation,
on a periodic basis (e.g. weekly or monthly) in amounts
sufficient to pay the insurance costs and hereby instruct it to
forward such funds to Gallagher by the 15th of each month.
Your cost (as described in “Cost and Consent to Cost
Change”) will be deducted from your settlement check. If
your settlement check is not enough to cover your
insurance cost, you will be asked to forward a check or
money order made payable to Gallagher Transportation
Services, 2345 Grand Boulevard, Suite 400, Kansas City,
MO 64108 immediately, or the coverage will be cancelled,
in accordance with policy terms and conditions.
8. Effective Date: Coverage shall become effective on the
date your Enrollment Form is accepted by Gallagher.
PLEASE READ ALL INFORMATION
CAREFULLY BEFORE SIGNING THE
APPLICATION ON THE REVERSE
SIDE
Gallagher Transportation Services
Arthur J. Gallagher & Co. Risk Management Services, Inc.
Administrative Office:
2345 Grand Blvd., Suite 400
Kansas City, MO 64108
(800) 279-7500
(816) 329-0891 (Fax)
Please fax all applications to Gallagher Transportation at (816) 329-0891
Occ.Acc Enrollment Form Edition 01.01.2011
Transportationword/PolicyForms/T4OccAccEnrollmentFormElectronic01.10.2011.doc
Page 2 of 2
PAY CARD CONSENT FORM
Please complete the following consent Form to sign up for your Pay Card account.
Print Name: ______________________ __________________________ __________________________
First
Middle
Last
Home Address: ________________________ ________________________ __________ ___________________
Street
City
State
Zip Code
The fees listed below will be deducted from your Pay Card balance for each transaction after your first transaction
each settlement load. You may withdraw your pay in full by going to a teller at a participating bank for a cash
disbursement. If it is your first transaction after your pay has been loaded to your Card, then the following fees will
not apply.
TRANSACTION TYPE
Cash Disbursement at Teller at Participating Banks
Cash Disbursement - Domestic
Cash Disbursement – International
ATM
ATM Withdrawal - Domestic
ATM Withdrawal – International
ATM Decline Fee - Domestic
ATM Decline Fee – International
ATM Balance Inquiry - Domestic
ATM Balance Inquiry - International
POS
POS Purchase – Domestic
POS Purchase - International
POS Purchase with Cashback - Domestic
POS Purchase with Cashback – International
POS Balance Inquiry - Domestic
POS Balance Inquiry - International
POS Refund - Domestic
POS Refund - International
POS Decline Fee - Domestic
POS Decline Fee - International
OTHER
Direct Deposit - Automatic
$0.50
Direct Deposit - Manual
$0.75
Comchek Draft Fee
$3.00
Invalid Claim Fee
$50.00
Replacement Card Fee
$2.00
Text Messaging (service available soon)
$N/A
Using PIN
Signing
$N/A
$N/A
$5.00
$8.00
$1.75
$5.00
$1.75
$5.00
$1.75
$5.00
N/A
N/A
N/A
N/A
N/A
N/A
$0.50
$5.00
$0.50
$5.00
$0.50
$5.00
$0.50
$5.00
$0.50
$5.00
$0.00
$0.00
N/A
N/A
N/A
N/A
$0.00
$0.00
$0.00
$0.00
Comdata will notify you of any changes in these Comdata Fees.
ATM owners outside of Comdata’s surcharge free ATM n etwork and other place s where you use your Card may
charge fees (even for a balance inquiry without completing a funds tra nsfer) that will be ded ucted from your Card
balance.
Page 37 of 43
If you use your Card ou tside the United States, or if you obtain funds (or make a purchase) in a currency other than
US Dollars (the currency in which your Card is issued), then the a mount deducted from your funds will be converted
into US Dollars by the card network. The card network will charge a Cross-Border Fee of 0.8% and Currency
Conversion Fee of 0.2 % (for a tot al fee of 1 % of the tra nsaction amount) to be included in the transaction am ount.
This card network cross border and currency conversion charge is independent of and in addition to any international
fee indicated in the Comdata Fees above.
You will not earn interest on your funds.
BY SIGNING BEL OW, I CONSENT TO RECEIVE MY COMMISSIONS BY ELECTRONIC TRANSFER TO MY PAY
CARD. I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THE CARDHOLDER AGREEMENT, AND I HAVE
READ, UNDERSTAND AND A GREE TO ALL OF T HE TERMS IN T HE CARDHOLDER AGREEMENT. I ALS O
UNDERSTAND AND AGREE TO THE FEES THAT I WILL INCUR USING THE PAY CARD.
Print Name:
Sign Name:
Contractor Number:
Date:
Page 38 of 43
W-9
Request for Taxpayer
Identification Number and Certification
Form
(Rev. October 2007)
Print or type
See Specific Instructions on page 2.
Department of the Treasury
Internal Revenue Service
Give form to the
requester. Do not
send to the IRS.
Name (as shown on your income tax return)
Business name, if different from above
Check appropriate box:
Individual/Sole proprietor
Corporation
Partnership
Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership)
Other (see instructions) �
Address (number, street, and apt. or suite no.)
�
Exempt
payee
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Social security number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Employer identification number
Part II
or
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. See the instructions on page 4.
Sign
Here
Signature of
U.S. person �
Date �
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
Purpose of Form
A person who is required to file an information return with the
IRS must obtain your correct taxpayer identification number (TIN)
to report, for example, income paid to you, real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a
resident alien), to provide your correct TIN to the person
requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S.
exempt payee. If applicable, you are also certifying that as a
U.S. person, your allocable share of any partnership income from
a U.S. trade or business is not subject to the withholding tax on
foreign partners’ share of effectively connected income.
Note. If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester’s form if it is
substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
● An individual who is a U.S. citizen or U.S. resident alien,
● A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United
States,
● An estate (other than a foreign estate), or
● A domestic trust (as defined in Regulations section
301.7701-7).
Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required to
pay a withholding tax on any foreign partners’ share of income
from such business. Further, in certain cases where a Form W-9
has not been received, a partnership is required to presume that
a partner is a foreign person, and pay the withholding tax.
Therefore, if you are a U.S. person that is a partner in a
partnership conducting a trade or business in the United States,
provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership
income.
The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding withholding
on its allocable share of net income from the partnership
conducting a trade or business in the United States is in the
following cases:
● The U.S. owner of a disregarded entity and not the entity,
Cat. No. 10231X
Form
W-9
(Rev. 10-2007)
Page 39 of 43
Form W-9 (Rev. 10-2007)
● The U.S. grantor or other owner of a grantor trust and not the
trust, and
● The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. If you are a foreign person, do not use Form
W-9. Instead, use the appropriate Form W-8 (see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally,
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income.
However, most tax treaties contain a provision known as a
“saving clause.” Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain types of
income even after the payee has otherwise become a U.S.
resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an
exemption from U.S. tax on certain types of income, you must
attach a statement to Form W-9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tax as a nonresident
alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under the
terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows
an exemption from tax for scholarship income received by a
Chinese student temporarily present in the United States. Under
U.S. law, this student will become a resident alien for tax
purposes if his or her stay in the United States exceeds 5
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of
Article 20 to continue to apply even after the Chinese student
becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of
the first protocol) and is relying on this exception to claim an
exemption from tax on his or her scholarship or fellowship
income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
If you are a nonresident alien or a foreign entity not subject to
backup withholding, give the requester the appropriate
completed Form W-8.
What is backup withholding? Persons making certain payments
to you must under certain conditions withhold and pay to the
IRS 28% of such payments. This is called “backup withholding.”
Payments that may be subject to backup withholding include
interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make the
proper certifications, and report all your taxable interest and
dividends on your tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect
TIN,
Page
2
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
5. You do not certify to the requester that you are not subject
to backup withholding under 4 above (for reportable interest and
dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Also see Special rules for partnerships on page 1.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such
failure unless your failure is due to reasonable cause and not to
willful neglect.
Civil penalty for false information with respect to
withholding. If you make a false statement with no reasonable
basis that results in no backup withholding, you are subject to a
$500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil and
criminal penalties.
Specific Instructions
Name
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part I
of the form.
Sole proprietor. Enter your individual name as shown on your
income tax return on the “Name” line. You may enter your
business, trade, or “doing business as (DBA)” name on the
“Business name” line.
Limited liability company (LLC). Check the “Limited liability
company” box only and enter the appropriate code for the tax
classification (“D” for disregarded entity, “C” for corporation, “P”
for partnership) in the space provided.
For a single-member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate from
its owner under Regulations section 301.7701-3, enter the
owner’s name on the “Name” line. Enter the LLC’s name on the
“Business name” line.
For an LLC classified as a partnership or a corporation, enter
the LLC’s name on the “Name” line and any business, trade, or
DBA name on the “Business name” line.
Other entities. Enter your business name as shown on required
federal tax documents on the “Name” line. This name should
match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or DBA
name on the “Business name” line.
Note. You are requested to check the appropriate box for your
status (individual/sole proprietor, corporation, etc.).
Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status,
then check the “Exempt payee” box in the line following the
business name, sign and date the form.
Page 40 of 43
Page
Form W-9 (Rev. 10-2007)
Generally, individuals (including sole proprietors) are not exempt
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
The following payees are exempt from backup withholding:
3
Part I. Taxpayer Identification
Number (TIN)
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt payees listed above, 1 through 15.
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
your TIN is your IRS individual taxpayer identification number
(ITIN). Enter it in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
If you are a single-member LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLC) on page 2), enter the owner’s SSN (or EIN, if the owner
has one). Do not enter the disregarded entity’s EIN. If the LLC is
classified as a corporation or partnership, enter the entity’s EIN.
Note. See the chart on page 4 for further clarification of name
and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5, Application
for a Social Security Card, from your local Social Security
Administration office or get this form online at www.ssa.gov. You
may also get this form by calling 1-800-772-1213. Use Form
W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for
Employer Identification Number, to apply for an EIN. You can
apply for an EIN online by accessing the IRS website at
www.irs.gov/businesses and clicking on Employer Identification
Number (EIN) under Starting a Business. You can get Forms W-7
and SS-4 from the IRS by visiting www.irs.gov or by calling
1-800-TAX-FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN,
write “Applied For” in the space for the TIN, sign and date the
form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily
tradable instruments, generally you will have 60 days to get a
TIN and give it to the requester before you are subject to backup
withholding on payments. The 60-day rule does not apply to
other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to
the requester.
Note. Entering “Applied For” means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign owner
must use the appropriate Form W-8.
IF the payment is for . . .
THEN the payment is exempt
for . . .
Part II. Certification
Interest and dividend payments
All exempt payees except
for 9
Broker transactions
Exempt payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
and patronage dividends
Exempt payees 1 through 5
Payments over $600 required
to be reported and direct
1
sales over $5,000
Generally, exempt
payees
2
1 through 7
1. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account
satisfies the requirements of section 401(f)(2),
2. The United States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding
include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under
the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section
584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or described in
section 4947.
1
2
See Form 1099-MISC, Miscellaneous Income, and its instructions.
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys’ fees, and
payments for services paid by a federal executive agency.
To establish to the withholding agent that you are a U.S. person,
or resident alien, sign Form W-9. You may be requested to sign
by the withholding agent even if items 1, 4, and 5 below indicate
otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt payees, see Exempt
Payee on page 2.
Signature requirements. Complete the certification as indicated
in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered active
during 1983. You must give your correct TIN, but you do not
have to sign the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts considered
inactive during 1983. You must sign the certification or backup
withholding will apply. If you are subject to backup withholding
and you are merely providing your correct TIN to the requester,
you must cross out item 2 in the certification before signing the
form.
Page 41 of 43
Form W-9 (Rev. 10-2007)
Page
3. Real estate transactions. You must sign the certification.
You may cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you
do not have to sign the certification unless you have been
notified that you have previously given an incorrect TIN. “Other
payments” include payments made in the course of the
requester’s trade or business for rents, royalties, goods (other
than bills for merchandise), medical and health care services
(including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA,
Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your
correct TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account:
1. Individual
2. Two or more individuals (joint
account)
3. Custodian account of a minor
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
trust (grantor is also trustee)
b. So-called trust account that is
not a legal or valid trust under
state law
5. Sole proprietorship or disregarded
entity owned by an individual
Give name and SSN of:
The individual
The actual owner of the account or,
if combined funds, the first
1
individual on the account
2
The minor
The grantor-trustee
The actual owner
The owner
1
2
3
4
1
3
Give name and EIN of:
For this type of account:
6. Disregarded entity not owned by an
individual
7. A valid trust, estate, or pension trust
8. Corporate or LLC electing
corporate status on Form 8832
9. Association, club, religious,
charitable, educational, or other
tax-exempt organization
10. Partnership or multi-member LLC
11. A broker or registered nominee
12. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
1
The owner
4
Legal entity
The corporation
The organization
4
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal
information such as your name, social security number (SSN), or
other identifying information, without your permission, to commit
fraud or other crimes. An identity thief may use your SSN to get
a job or may file a tax return using your SSN to receive a refund.
To reduce your risk:
● Protect your SSN,
● Ensure your employer is protecting your SSN, and
● Be careful when choosing a tax preparer.
Call the IRS at 1-800-829-1040 if you think your identity has
been used inappropriately for tax purposes.
Victims of identity theft who are experiencing economic harm
or a system problem, or are seeking help in resolving tax
problems that have not been resolved through normal channels,
may be eligible for Taxpayer Advocate Service (TAS) assistance.
You can reach TAS by calling the TAS toll-free case intake line
at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing
schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business emails and
websites. The most common act is sending an email to a user
falsely claiming to be an established legitimate enterprise in an
attempt to scam the user into surrendering private information
that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails.
Also, the IRS does not request personal detailed information
through email or ask taxpayers for the PIN numbers, passwords,
or similar secret access information for their credit card, bank, or
other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tax Administration at
1-800-366-4484. You can forward suspicious emails to the
Federal Trade Commission at: spam@uce.gov or contact them at
www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).
Visit the IRS website at www.irs.gov to learn more about
identity theft and how to reduce your risk.
The partnership
The broker or nominee
The public entity
List first and circle the name of the person whose number you furnish. If only one person
on a joint account has an SSN, that person’s number must be furnished.
Circle the minor’s name and furnish the minor’s SSN.
You must show your individual name and you may also enter your business or “DBA”
name on the second name line. You may use either your SSN or EIN (if you have one),
but the IRS encourages you to use your SSN.
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN
of the personal representative or trustee unless the legal entity itself is not designated in
the account title.) Also see Special rules for partnerships on page 1.
Note. If no name is circled when more than one name is listed,
the number will be considered to be that of the first name listed.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,
dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
Page 42 of 43
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